13 Pathophysiology and treatment of sarcoidosis-associated SFN Although granulomas are the hallmark of sarcoidosis, SFN in sarcoidosis patients does not appear to be directly related to the granulomatous inflammation of small nerve fibers. Therefore, the pathophysiology of sarcoidosis-associated SFN is comparable to the pathophysiology of SFN in general, as described above. Both general symptomatic treatment of SFN, as described in Figure 4, and treatment aimed at suppressing the underlying disorder apply to sarcoidosis-associated SFN. For inflammation-mediated SFN, such as sarcoidosis-associated SFN, suppression of inflammation seems a logical step in the treatment strategy. Although randomized controlled trials on immunosuppressive treatment for SFN in patients with sarcoidosis are lacking, case reports and small case series suggest that anti-TNF-α treatments, such as infliximab, may be effective for symptomatic treatment of sarcoidosis-associated SFN.55–57 Furthermore, specific treatment for autonomic dysfunction can be administered depending on the affected organs. The autonomic nervous system innervates viscera, vascular smooth muscle, endocrine and exocrine glands, the immune system, and soft tissues. Associated symptoms, as described in Table 2, may occur as consequence of autonomic dysfunction. Patients with sarcoidosisassociated SFN show an increased prevalence of autonomic dysfunction.20 For example, cardiac autonomic dysfunction may occur in patients with sarcoidosis and SFN and is associated with increased mortaility.20,58 In addition, the beta-blocker carvedilol has been suggested for its potential to improve the parasympathetic activity of the cardiac sympathetic nervous system, which is more profound than for instance the more widely used beta-blocker metoprolol.59 In conclusion, there is need for further research to understand how to accurately diagnose and treat small fiber neuropathy in sarcoidosis patients, potentially leading to improved management and quality of life for affected individuals. 1 14 1
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